HIV deaths in Zambia highly underreported
HIV mortality among patients on ART is highly underreported in four Zambian provinces, according to researchers. Being late for appointments and lost to follow-up were both associated with mortality, they wrote in PLoS Medicine.
Their findings, however, can guide both HIV death surveillance and improve HIV programs both nationally and globally, they added.
“Even as we strive to reduce new HIV infections and end the HIV pandemic as a public health threat, we must not lose sight of premature deaths occurring among people living with HIV who are on treatment,” researcher Charles B. Holmes, MD, MPH, co-director of the Georgetown University Center for Global Health and Quality, said in a news release. “HIV treatment is not a ‘set it and forget it’ proposition. Deaths often occur outside of the health care system and are therefore ‘silent’ events that are unknown to those providing or managing care.”
The researchers assessed the electronic medical records of patients with HIV who visited any one of 64 clinics across four provinces in Zambia between August 2013 and August 2015. They identified a probability sample of patients lost to follow-up, as well as a random sample of 150 patients who were actually lost to follow-up. Health workers traced lost patients via medical records, telephone contact and in-person follow-up visits in the communities.
Patients who were more than 14 days late for an appointment were classified as late, whereas those more than 90 days late were classified as lost to follow-up. Additionally, patients who started ART during the 2 years before the study were deemed new ART users.
Altogether, 165,464 patients made visits to the facilities involved in the study. Of those, 49,129 were new ART users. In the sampling analysis, the researchers found that the true 2-year cumulative mortality rate among all ART users was 7% compared with the reported rate of 1.9%. The true 2-year mortality rate among new ART users was 8.3% compared with the reported 2.1%. Provincial-level mortality rates rose threefold to eightfold “once corrected for true outcomes,” the researchers said.
The corrected rates among individual clinics varied widely, with an interquartile range of 3.5 to 7.5 deaths per 100 person-years, according to Holmes and colleagues. The highest rate among new ART users was 13.4 deaths per 100 person-years.
Patients who were always in care accounted for 8.8% of deaths. In contrast, 13.7% of deaths occurred in those with a history of lateness but who were in care when they died, and 29.1% occurred in those with a history of being lost to follow-up but who were in care when they died. According to the researchers, 36.7% of deaths occurred in patients while lost to follow-up.
The researchers concluded in part that HIV programs must involve closer attention to patient care and better tracking of patient outcomes.
“We believe our scalable approach, which builds on and extends earlier sampling methods, provides actionable data to clinic, provincial and national decision-makers to ensure the HIV program in Zambia is able to become more patient-centered and impactful,” Holmes said. “We believe our study also highlights the critical need for investments in vital status registries and data systems to enable better visibility into patient outcomes. These investments are critical, not just for the HIV response, but for broader efforts to combat chronic conditions such as noncommunicable diseases and achieve universal health coverage.” – by Joe Green
Disclosures: Holmes reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.